STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS SEE REVERSE SIDE FOR INSTRUCTIONS WORKERS' COMPENSATION APPEALS BOARD APPLICATION FOR ADJUDICATION OF CLAIM (Death Case) (PRINT OR TYPE NAMES AND ADDRESSES) CASE No. (APPLICANT'S ADDRESS AND ZIP CODE) M (APPLICANT) (DECEASED EMPLOYEE) Social Security No. (EMPLOYER - STATE IF SELF-INSURED) (EMPLOYER'S ADDRESS AND ZIP CODE) (EMPLOYER'S INSURANCE CARRIER OR, IF SELF-INSURED, ADJUSTING AGENCY) (INSURANCE CARRIER OR ADJUSTING AGENCY'S ADDRESS) IT IS CLAIMED THAT: 1. Deceased employee, born (DATE OF BIRTH) while as employed as a (OCCUPATION AT TIME OF INJURY) on (DATE OF INJURY) , at (ADDRESS) (CITY) (STATE) (ZIP CODE) , by the employer sustained (STATE WHAT PARTS OF BODY WERE INJURED) injury arising out of and in the course of employment to 2. The injury occurred as follows: (EXPLAIN WHAT EMPLOYEE WAS DOING AT TIME OF INJURY AND HOW INJURY WAS RECEIVED) resulting in death on (DATE OF DEATH) 3. 4. 5. 6. Actual earnings at time of injury were: (GIVE WEEKLY OR MONTHLY SALARY OR HOURLY RATE AND NUMBER OF HOURS WORKED PER WEEK) The injury caused disability as follows: (SPECIFY LAST DAY OFF WORK DUE TO THIS INJURY AND BEGINNING AND ENDING DATES OF ALL PERIODS OFF DUE TO THIS INJURY) Compensation was paid (YES) (NO) $ (TOTAL PAID) (YES) (NO) $ (WEEKLY RATE) (DATE OF LAST PAYMENT) Medical treatment was received (DATE OF LAST TREATMENT) . All treatment was furnished by the employer or other treatment was provided or paid by insurance company (YES) (NO) (NAME OF PERSON OR AGENCY PROVIDING OR PAYING FOR MEDICAL CLAIM) Did Medi-Cal pay for any health care related to this claim (YES) (NO) Doctors not provided or paid for by employer or insurance company, who treated or examined for this injury are: (STATE NAMES AND ADDRESSES OF SUCH DOCTORS AND NAMES OF HOSPITALS TO WHICH SUCH DOCTORS ADMITTED INJURED) 7. 8. Defendants have paid burial expense (YES) (NO) TOTAL PAID The employee left surviving the following dependents: DATE OF BIRTH NAME (if under 18) RELATIONSHIP TO THE EMPLOYEE ADDRESS WHEREFORE, applicant requests a hearing and an award of: Death benefit Burial expense Compensation accrued and unpaid Dated at Unpaid medical bills Other (specify) and all other appropriate benefits provided by law. , California, (CITY) (APPLICANT'S ATTORNEY) (DATE) (ADDRESS AND TELEPHONE NUMBER OF ATTORNEY) (APPLICANT'S SIGNATURE) American LegalNet, Inc. www.FormsWorkFlow.com DIA WCAB Form 2 (Rev. 7/81) DIA-2 INSTRUCTIONS FlLING AND SERVICE OF A DECLARATION OF READINESS (DWC Form 10250.1) IS PREREQUISITE TO THE SETTING OF A CASE FOR HEARING. Effect of Filing Application Filing of this application begins formal proceedings against the defendants named in your application. Assistance in Filling out Application You may request the assistance of an information and assistance officer of the Division of Workers' Compensation. Right to Attorney You may be represented by an attorney or agent, or you may represent yourself. The attorney fee will be set by DWC judge at the time the case is decided and is ordinarily payable out of your award. Filling Out Application All blanks in the application shall be completed. Where the information is unknown, place "unknown" in the blank. If medical treatment is paid for by Medi-Cal, Medicare, group health insurance or private carrier, please specify. Service of Documents Your attorney or agent will serve all documents in accord with Labor Code Section 5501 and Section 10500 of the Workers' Compensation Appeals Board's Rules of Practice and Procedure. If you have no attorney or agent, copies of this application will be served by the Division of Workers' Compensation on all parties. If you file any other document, you must mail or deliver a copy of the document to all parties in the case. IMPORTANT! If any applicant is under 18 years of age, it will be necessary to file Petition for Appointment of Guardian ad Litem. American LegalNet, Inc. www.FormsWorkFlow.com